Practice-based evidence: Evaluating the quality of occupational therapy patient records as evidence for practice

Buchanan, Helen; Jelsma, Jennifer; Siegfried, Nandi

doi:10.17159/2310-3833/2016/v46n1a13

Cited by 7 publications

(10 citation statements)

References 19 publications

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“…Although evidence indicates electronic documentation improves quality and speed, many occupational therapists continue to use the handwritten form of documentation rather than implement an EHR system. Occupational therapists are legally and ethically required to document their skilled services, but proper documentation also enables the occupational therapy profession to construct a body of valuable data that can bolster the profession (Buchanan et al, 2016).…”

Section: Current Evidence For Electronic Documentationmentioning

confidence: 99%

“…The EasySteps EHR eliminates redundancy from the documentation process to allow more time to include clinical reasoning and rationale for interventions. Documentation that provides accurate information, clinical reasoning for interventions, and a complete description of the services provided can allow a profession to build a collection of data that serves as the foundation of the profession (Buchanan et al, 2016).…”

Section: Figure 5 Median Word Countmentioning

confidence: 99%

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Effectiveness of Electronic Documentation: A Case Report

Wroten¹,

Zapf²,

Hudgins³

2020

The Open Journal of Occupational Therapy

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Background: : This case report aims to inform the occupational therapist and other health care professionals of documentation best practices. Method: : This qualitative case report uses an exploratory approach to compare the quality of one participant's handwritten documentation to her electronic documentation. Outcome measures include the Accuracy Rationale Completeness (ARC) Audit to score the quality of the notes and quantity of words, and an informal discussion with the participant about her experiences using both types of documentation. Results: : The participant's 25 handwritten notes scored a sum of 321 and the 25 electronic notes scored a sum of 517 out of 650 possible points on the ARC Audit, indicating a 61% overall improvement in scores for electronic notes. All 13 attributes of the ARC Audit indicated a higher score for electronic documentation. The participant wrote 333% more words and reported that she saved up to 10 min per note using the electronic health record system. Conclusion: : This case report illustrates that the participant produced more accurate and comprehensive documentation, including improved clinical reasoning and rationale for therapy services in less time when using an electronic health record system. Comments The primary author acknowledges that she is the developer of the EasySteps electronic health record system; however, the ARC Audit used to score the notes was based on AOTA Guidelines for Documentation of Occupational Therapy.

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Section: Current Evidence For Electronic Documentationmentioning

confidence: 99%

Section: Figure 5 Median Word Countmentioning

confidence: 99%

Effectiveness of Electronic Documentation: A Case Report

Wroten¹,

Zapf²,

Hudgins³

2020

The Open Journal of Occupational Therapy

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“…Mais recentemente, o estudo "Practice-based evidence: evaluating the quality of occupational therapy patient records as evidence for practice" apresentou a análise de 240 registros realizados por 49 terapeutas ocupacionais atuantes em instituições de saúde de uma região da África do Sul. A auditoria nos registros foi realizada por meio do uso de checklist formulado pelos pesquisadores e fundamentado a partir de revisão sistemática 16 .…”

Section: Qualidade Documental: Apontamentos De Dados Empíricosunclassified

“…Entre os resultados os autores verificaram inconsistências nas informações sobre avaliação da linha de base e informações referentes à reavaliação, fato apontado como entrave para a determinação da eficácia da assistência em terapia ocupacional. A baixa pontuação obtida na auditoria demonstrou que os registros não contêm informações suficientes para produzir dados robustos para a criação de evidências científicas, sendo sinalizado pelos autores a necessidade de ser concebidas maneiras gerenciáveis de documentar a prática da terapia ocupacional 16 .…”

Section: Qualidade Documental: Apontamentos De Dados Empíricosunclassified

Registro em prontuário: reflexões sobre a qualidade documental na terapia ocupacional

Bombarda

Joaquim

2019

Rev. Ter. Ocup. Univ. São Paulo (Online)

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Os registros de Terapia Ocupacional têm por finalidade descrever o processo terapêutico tornando explícito o pensamento crítico, o raciocínio profissional e a tomada de decisões do terapeuta ocupacional. Contudo, a importância do prontuário vai além do âmbito assistencial, visto essas anotações também ser utilizadas nocontexto administrativo, educacional e científico. Mas o desempenho deste procedimento é realizado com qualidade pelos terapeutas ocupacionais? Visando discorrer sobre o tema, serão apresentados pelos autores apontamentos sobre a qualidade dos registros, a partir de uma análise reflexiva norteada pelas diretrizes da profissão sobre documentação. Como principais apontamentos, pode-se afirmar que a prática documental dos terapeutas ocupacionais ocorre de modo inconsistente, fator vinculado ao desconhecimento das diretrizes da profissão, à dificuldades com a linguagem técnica e ao processo de formação inicial e continuada. Recomenda-se a ampliação e aprofundamento de pesquisas sobre o tema para obtenção de estratégias educacionais mais eficazes e sistematizações de modelos de registros melhor gerenciáveis.

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“…An article that examines "…how comprehensively occupational therapists documented… their assessment and treatment of the clients for which they were responsible" 13 , follows. As these docu-EDITORIAL COMMENT ments may be used not only to provide the evidence of effective practices but also for legal purposes, accurate and complete record keeping is an important part of patient intervention.…”

Section: Issn On-line 2310-3833mentioning

confidence: 99%

Editorial Comment

Concha¹

2016

S. Afr. j. occup. ther

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Practice-based evidence: Evaluating the quality of occupational therapy patient records as evidence for practice

Cited by 7 publications

References 19 publications

Effectiveness of Electronic Documentation: A Case Report

Effectiveness of Electronic Documentation: A Case Report

Registro em prontuário: reflexões sobre a qualidade documental na terapia ocupacional

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